Article [incomplete] published in the Canadian Journal of Psychiatry, December, 2015

1. ACADEMIC JOURNAL ARTICLE
Canadian Journal of Psychiatry
Misattributions and Potential Consequences: The
Case of Child Mental Health Problems and Fetal
Alcohol Spectrum Disorders
By McLennan, John D.
Article excerpt
Numerous Canadian agencies have prioritized services for people
diagnosed with FAS and broader construct FASD. This
prioritization extends to prevention interventions aimed at
reducing or eliminating PAE. The many difficulties identified as
associated with FAS, FASD, and PAE is one of the justifications
for this prioritization. Mental health symptoms and disorders are
among the most commonly highlighted challenges experienced by
people labeled with FAS or FASD or exposed to alcohol in utero.
However, the extent of the relation between the FAS, FASD, and
PAE cluster and mental health symptom and disorder clusters may
be inflated secondary to at least 3 factors: diagnostic criteria
overlap and etiologic assumptions, referral bias, and failure to
control for confounding variables when assessing associations.
Lack of awareness of these factors may lead to dissemination of
misinformation, which could adversely distort the development
and provision of mental health services.
Diagnostic criteria for conditions falling under the FASD umbrella
have been operationalized in several different guidelines. The 2005
Canadian guideline1 aimed, in part, to harmonize aspects of the 2
leading approaches at the time, that is, those of the Institute of
Medicine2 and the Washington 4-digit diagnostic code.3
Guidelines typically include the complete syndrome, FAS, and
require positive findings in 4 domains: problematic patterns of
alcohol exposure in utero (for example, from maternal binge
drinking), growth abnormalities (for example, low birth weight for
gestational age), facial dysmorphology (for example, short

2. palpebral fissures), and CNS neurodevelopment abnormalities (for
example, microcephaly at birth).2 Guidelines then typically go on
to describe various partial syndromes. In the case of the Canadian
guideline, the following partial syndromes are included: FAS
(without confirmed alcohol exposure), partial FAS, and ARND.1
Difficulties identified within children with high PAE, who do not
have classical dysmorphic manifestations, is used to support the
inclusion of partial syndromes.4 However, this broadening likely
contributes to problematic overlap with those children with mental
health difficulties for whom PAE may be present but for whom it
is not etiologic. This is particularly problematic as there is no
consensus on a pathognomonic
behavioural manifestation of PAE or FASD. Although some
propose a unique mental health profile linked to FASD,5 such
profiles are based on small clinical samples and do not appear have
been independently replicated using a nonreferred population.
Nevertheless, a resulting 10-item screening tool appears to be
receiving national promotion in Canada.6
Concerns that weaknesses in the operationalization of partial
FASD syndromes may lead to misattribution of PAE as causal for
various difficulties (for example, behavioural problems) been
raised in critiques of the 2 dominant diagnostic approaches used in
the field,2,3 that is, US sources for the Canadian guidelines.7 The
ARND diagnosis, within the Canadian guidelines, requires
"evidence of impairment in three or more of the following CNS
domains: hard and soft neurologic signs; brain structure; cognition;
communication; academic achievement; memory; executive
functioning and abstract reasoning; attention deficit/hyperactivity;
adaptive behavior, social skills, and social communication."1, p
S12
However, abnormalities in 3 of the listed domains would also be
commonly found in many children with various mental health
disorders. PAE may not be uncommon in children with such
problem clusters. However, the fraction for whom PAE is

3. primarily etiologic is unknown, and to assume it is typically the
leading etiology is highly problematic.8
Complicating the picture is the inclusion of an etiologic variable,
in this case PAE, in the diagnostic criteria for FASD. This is at
odds with a key direction taken in psychiatry as reflected in
contemporary versions of the DSM, that is, to avoid etiologic
assumptions within diagnostic criteria. …